Jamie Smith

Duration of Diabetes Predicts Aortic Pulse Wave Velocity and Vascular Events in Alström Syndrome

Context: Alström syndrome is characterized by increased risk of cardiovascular disease from childhood. Objective: To explore the association between risk factors for cardiovascular disease, aortic pulse wave velocity, and vascular events in Alström syndrome. Design: Cross-sectional analyses with 5-year follow-up. Setting: The UK NHS nationally commissioned specialist clinics for Alström syndrome. Patients: Thirty-one Alström patients undertook vascular risk assessment, cardiac studies, and aortic pulse wave velocity measurement. Subsequent clinical outcomes were recorded. Interventions: Insulin resistance was treated with lifestyle intervention and metformin, and diabetes with the addition of glitazones, glucagon-like peptide 1 agonists, and/or insulin. Thyroid and T deficiencies were corrected. Dyslipidemia was treated with statins and nicotinic acid derivatives. Cardiomyopathy was treated with standard therapy as required. Main Outcome Measures: The associations of age, gender, and risk factors for cardiovascular disease with aortic pulse wave velocity were assessed and correlated with the effects of reduction in left ventricular function. Vascular events were monitored for 5 years. Results: Aortic pulse wave velocity was positively associated with the duration of diabetes (P = .001) and inversely with left ventricular ejection fraction (P = .036). Five of the cohort with cardiovascular events had higher aortic pulse wave velocity (P = .0247), and all had long duration of diabetes. Conclusions: Duration of diabetes predicted aortic pulse wave velocity in Alström syndrome, which in turn predicted cardiovascular events. This offers hope of secondary prevention because type 2 diabetes can be delayed or reversed by lifestyle interventions.

Diagnostic difficulties with a lipaemic blood sample

A 38 year old woman with type 2 diabetes controlled by her diet was referred for emergency assessment in hospital by her general practitioner after complaining of epigastric pain radiating to her back. The patient was tachycardic and had epigastric tenderness on examination. A diagnosis of acute pancreatitis was suspected, but the patient’s serum amylase concentration was normal at 52 U/l (normal range 28-100 U/l) so alternative diagnoses were considered. The blood sample was noted to be lipaemic and a lipid profile was requested: serum cholesterol level was 27.9 mmol/l (1078.9 mg/dl) and serum triglyceride concentration was found to be greater than 100 mmol/l (8900 mg/dl). Chest radiograph did not show any gas under the diaphragm. The patient was prescribed simvastatin 40 mg once a day and commenced on an insulin infusion to decrease her serum triglyceride levels. She was also treated with intravenous fluids, but her abdominal pain worsened during the first 24 hours of hospital admission despite analgesia. ### 1) What is the suspected diagnosis and what is the likely cause? #### Short answer The suspected diagnosis is acute pancreatitis secondary to hypertriglyceridaemia. #### Long answer Acute pancreatitis is a potentially life threatening condition with an incidence of 100 …

Relationships between glucose, energy intake and dietary composition in obese adults with type 2 diabetes receiving the cannabinoid 1 (CB1) receptor antagonist, rimonabant

BackgroundWeight loss is often difficult to achieve in individuals with type 2 diabetes and anti-obesity drugs are often advocated to support dietary intervention. Despite the extensive use of centrally acting anti-obesity drugs, there is little evidence of how they affect dietary composition. We investigated changes in energy intake and dietary composition of macro- and micronutrients following therapy with the endocannabinoid receptor blocker, rimonabant.Methods20 obese patients with type 2 diabetes were studied before and after 6 months dietary intervention with rimonabant. Dietary intervention was supervised by a diabetes dietician. Five-day food diaries were completed at baseline and at 6 months and dietary analysis was performed using computer software (Dietplan 6).ResultsAfter 6 months, (compared with baseline) there were reductions in weight (107 ± 21Kg versus 112 ± 21, p < 0.001, 4% body weight reduction), and improvements in HbA1c (7.4 ± 1.7 versus 8.0 ± 1.6%, p < 0.05) and HDL cholesterol. Intake of energy (1589 ± 384 versus 2225 ± 1109 kcal, p < 0.01), carbohydrate (199 ± 74 versus 273 ± 194 g, p < 0.05), protein (78 ± 23 versus 98 ± 36 g, p < 0.05), fats (55 ± 18 versus 84 ± 39 g, p < 0.01) and several micronutrients were reduced. However, relative macronutrient composition of the diet was unchanged. Improvement in blood glucose was strongly correlated with a reduction in carbohydrate intake (r = 0.76, p < 0.001).ConclusionsIn obese patients with type 2 diabetes, rimonabant in combination with dietary intervention led to reduced intake of energy and most macronutrients. Despite this, macronutrient composition of the diet was unaltered. These dietary changes (especially carbohydrate restriction) were associated with weight loss and favourable metabolic effects.

Use of a somatostatin analogue in treating severe hypoglycaemia and neuroglycopaenia, in association with hyperinsulinaemia, post bariatric surgery

Dumping syndrome is a well‐recognised phenomenon post bariatric surgery. However, are all post‐prandial symptoms in such patients simply a result of classical dumping? Our case clearly highlights that as clinicians we should be alert to the possibility of post‐prandial hyperinsulinaemic hypoglycaemia leading to severe neuroglycopaenia.

RAPID RESPONSES FROM BMJ.COM: Drawbacks of primary prevention risk tables to assess cardiovascular risk in type 2 diabetes

Following is an edited excerpt from one of the Rapid Responses generated by this article, which can be read in their entirety at http://bmj.com/cgi/eletters/326/7383/251—Editor